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iy � , <br /> `�� <br /> � � � z �� <br /> �i �� 8.. <br /> � <br /> y� �i��Y O� ����� <br /> �`� _�; ��,TN �:�t "q <br /> „ y,:'" �"'`� ��'��' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> .� <br /> �. <br /> � �i r #�#,;:� <br /> ��������,. <br /> y�,,� ,y� � , On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would Iike to inform you that your request for a permit or <br /> Iicense from the City of Orono or any of its departments may require <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other Iocal , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councii. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Your full name is required to process this apt�lica�ica or <br /> permit. <br /> j�C S < �3'�t.�,wiV C�I?�Z IGSG�(1' <br /> First Middle Last <br /> r 3 r� � ���-y��-i�� �c- �_�/"� <br /> Address <br /> ��--,�Y z�-T-zt �`y�r �5��>/ <br /> City State Zlp <br /> �f 7�-i/S� <br /> Phone <br /> I understand my rights as stated above. <br /> �— <br /> _ �_ ___-- <br /> -----�- <br /> —��- <br /> Signature <br /> BUILDING&ZONING-473-7357 • ADMINISTRATION&FINANCE-473-7358 • PUBLIC WORKS-473-7359 <br /> ASSESSING <br />